Attention-deficit hyperactivity disorder controversies
From Wikipedia, the free encyclopedia
The causes, diagnosis, and the treatment of attention-deficit hyperactivity disorder (ADHD) have been the subject of active debate at least since the 1970s. For various reasons, ADHD remains one of the most controversial psychiatric disorders despite being a well validated clinical diagnosis. Possible overdiagnosis of ADHD, the use of stimulant medications in children, and the methods by which ADHD is diagnosed and treated are some of the main areas of controversy.
According to the National Institute for Health and Clinical Excellence (NICE) ADHD has attracted controversy from many people. The criticisms include: how it is diagnosed, negative stereotyping of children, risks of other conditions being misdiagnosed as ADHD and alleged hegemonic practices of the American Psychiatric Association. Some even question the very existence of ADHD.:p.23
NICE concluded that while it is important to acknowledge the body of academic literature which raise controversies and criticisms surrounding ADHD for the purpose of developing clinical guidelines, it is not possible to offer alternative methods of assessment (i.e. ICD 10 and DSM IV) or therapeutic treatment recommendations. NICE stated that this is because the current therapeutic treatment interventions and methods of diagnosis for ADHD are based on the dominant view of the academic literature.:p.133 NICE further concluded that despite such criticism, ADHD represented a valid clinical condition :p.138 with genetic, environmental, neurobiological, and demographic factors.:p.139 Although the diagnosis has a high level of support from clinicians and most medical authorities, a number of alternative theories explaining the symptoms of ADHD have been proposed which range from describing ADHD as part of the normal spectrum of behavior instead of a disorder to rejecting its existence outright. These views include the Hunter vs. farmer theory, Neurodiversity, and the Social construct theory of ADHD.
The best course of ADHD management is also a source of debate. Stimulants are the most commonly prescribed medication for ADHD, and, according to the National Institute of Mental Health, "under medical supervision, stimulant medications are considered safe". Safety concerns exist with concerns regarding the higher rates of schizophrenia and bipolar disorder as well as increased severity of these disorders in individuals with a past history of stimulant use for ADHD in childhood. The use of stimulant medications for the treatment of ADHD has generated controversy because of undesirable side effects, uncertain long term effects, and social and ethical issues regarding their use and dispensation. Children comprise the majority of ADHD diagnoses, but because they are unable to give informed consent due to their age, treatment decisions are ultimately determined by their legal guardians on their behalf. Ethical and legal issues also arise from the promotion of stimulants to treat ADHD by groups and individuals who receive money from drug companies.
1 Status as a disorder
1.1 Skepticism about the diagnosis
1.2 Concerns about methods of diagnosis
1.3 Over / under diagnosis
1.4 Changing diagnostic criteria
1.5 Views of ADHD outside North America
1.6 Anti-psychiatry movement
1.8 Personality trait
2 Questions concerning the cause
2.1 ADHD as a biological illness
2.2 Neuroimaging and ADHD
2.3 Hunter vs. farmer theory of ADHD
2.5 Social construct theory of ADHD
3 Concerns about medication
3.1 Frequency of stimulant use
3.2 Concerns about side effects and long term effectiveness
3.3 Long term effects
3.5 Non specific nature
3.6 Stimulant misuse
4 Substance use disorders
6 Financial conflicts of interest
7 Concerns about the impact of labeling
8 In politics and the media
8.1 North America
8.2 United Kingdom
9 Imitation of symptoms
10 See also
12 External links
Status as a disorder
The controversy surrounding ADHD involves clinicians, scientists, teachers, policymakers, parents and the media with opinions regarding ADHD ranging from those who do not believe it exists to those who believe that there are genetic and physiological bases for the condition. Controversy continues to grow over the diagnosis, treatment and cause and etiology of ADHD, as well as concerns surrounding the long term effects of the stimulants used to treat ADHD. The controversies around ADHD have been on-going at least since the 1970s. Questioning of the safety of stimulants began in the 1990s among the general population when anti-Ritalin advocates denounced it as "kiddie cocaine". In the most accepted authority on clinical diagnoses of psychological behavior, the DSM-IV, ADHD is included as a genuine disorder while significant controversy surrounds how it is diagnosed and treated.
Researchers from McMaster University identified five features of ADHD that contribute to its controversial nature:
It is a clinical diagnosis for which there are no laboratory or radiological confirmatory tests or specific physical features.
Diagnostic criteria have changed frequently.
There is no curative treatment, so long-term therapies are required.
Therapy often includes stimulant drugs that are thought to have abuse potential.
The rates of diagnosis and of treatment substantially differ across countries.
Skepticism about the diagnosis
Skepticism about the validity of the diagnosis was in 2002 a minority opinion in the general U.S. population; a survey found that of the 64% who had heard of ADHD, 78% believed it to be a "real disease". In the United States, African-American parents state that their friends and family are often unsure about the legitimacy of ADHD. In a small study from 1999 of nine Australian health care professionals, three were skeptical of ADHD as a valid diagnosis. In 1998 Fred Baughman stated "ADHD is total, 100% fraud" as a counter claim to Russell Barkley's 1995 comment that "ADHD is real". Meyers states that in the 1990s some social conservatives began to see ADHD as a sign of societies' hostility towards men and as an infringement upon the family.
In 2002, Russell Barkley, a prominent researcher and author on the subject of ADHD, published The International Consensus Statement on Attention Deficit Hyperactivity Disorder (ADHD), signed by 86 psychiatrists and psychologists, including several of the most widely published and cited researchers in psychiatry, which asserts the existence of ADHD and denies the existence of controversy within the medical community. Two critiques of their statements have since been published in the peer reviewed literature questioning the negative tone they have used to describe researchers with views differing from their own.
In a June 2009 paper, the chair of the DSM-IV Task Force referred to one of DSM-IV’s unintended consequences as false "epidemics," attributing the sudden increases in the diagnosis of autism, bipolar disorder and ADHD to changes made in the DSM-IV definitions of those disorders.
In 2002, 8% of readers of the British Medical Journal who answered an online survey listed ADHD as one of the 10 top "non-diseases". The BMJ survey defined non-diseases as meaning "a human process or problem that some have defined as a medical condition but where people may have better outcomes if the problem or process was not defined in that way." They did not deny that non-diseases do entail real problems or suffering. For example, obesity, hypercholesterolaemia, and menopause all received a greater number of votes on this survey.
Robins and Guze's criteria assert that the validity of any diagnosis must derive from empirical research and that some of this research must examine the neurobiologic causes and correlates of disorders. The Robins and Guze criteria view the validity of diagnoses as arising from empirical studies demonstrating the following: 1) the diagnosis has well-defined clinical correlates, 2) the diagnosis can be delimited from other diagnoses, 3) the disorder has a characteristic course and outcome, 4) the disorder shows evidence of heritability from family and genetic studies, 5) data from laboratory studies demonstrate other neurobiologic correlates of the disorder, and 6) the disorder shows a characteristic response to treatment. A 2005 review recognizes the ongoing controversial nature of ADHD among both clinicians and the general public. It found that it fulfills the Robins and Guze criteria which support the idea that ADHD is a valid diagnostic category. A 2008 review, however, came to the opposite conclusion and states that: "Evidence for a genetic or neuroanatomic cause of ADHD is insufficient. [...] ADHD is unlikely to exist as an identifiable disease."
Concerns about methods of diagnosis
ADHD is controversial in part because most children are diagnosed and treated based on decisions made by their parents and clinicians with teachers being the primary source of diagnostic information. Only a minority, about 20%, of children who end up with a diagnosis of ADHD show hyperactive behavior in the physician's office.
The number of people diagnosed with ADHD in the U.S. and UK has grown dramatically over a short period of time. Critics of the diagnosis, such as Dan P. Hallahan and James M. Kauffman in their book Exceptional Learners: Introduction to Special Education, have argued that this increase is due to the ADHD diagnostic criteria being sufficiently general or vague to allow virtually anybody with persistent unwanted behaviors to be classified as having ADHD of one type or another, and that the symptoms are not supported by sufficient empirical data.
Tools that are designed to analyze a person's behavior, such as the Brown scale or the Conners scale, for example, attempt to assist parents and providers in making a diagnosis by evaluating an individual on typical behaviors such as "Hums or makes other odd noises", "Daydreams" and "Acts 'smart'"; the scales rating the pervasiveness of these behaviors range from "never" to "very often". Connors[who?] states that, based on the scale, a valid diagnosis can be achieved; critics, however, counter Connors' proposition by pointing out the breadth with which these behaviors may be interpreted. This becomes especially relevant when family and cultural norms are taken into consideration; this premise leads to the assumption that a diagnosis based on such a scale may actually be more subjective than objective. (See cultural subjectivism.)
Some of the criticism does not reject the concept of ADHD as a valid disorder, but alleges that children with problematic behavior are often diagnosed with ADHD when the behavior may result from other causes. Critics state that some children diagnosed with ADHD, or labeled ADHD by parents or teachers, are normal but do not behave in the way that responsible adults want them to behave.
ADHD is purely a diagnosis by exclusion with no definitive physical test. This leads to situations where one doctor would say a child needs psychotropic medication while another doctor could say the child is perfectly normal. Concern exists that "elevated but still developmentally normal levels of motor activity, impulsiveness, or inattention" traits of childhood could be inappropriately interpreted as ADHD.
In 2005 82% of teachers in the United States considered ADHD to be over diagnosed while 3% considered it to be under diagnosed. In China 19% of teachers considered ADHD to be over diagnosed while 57% considered it to be under diagnosed.
Changing diagnostic criteria
For over seventy years in the United States, symptoms of what is now called ADHD have had different labels. The fact that the diagnostic criteria and the name used to describe the set of characteristics that make up ADHD have changed over time has led to concerns.
Views of ADHD outside North America
In 2009, the British Psychological Society and the Royal College of Psychiatrists, in collaboration with the National Institute for Clinical Excellence (NICE), released a set of diagnosis and treatment guidelines for ADHD. These guidelines reviewed studies by Ford et al. that found that 3.6% of boys and 0.85% of girls in Britain qualified for a diagnosis of ADHD using the American DSM-IV guidelines. The guidelines go on to state that the prevalence drops to 1.5% when using the ICD-10 diagnosis of Hyperkinetic Disorder. The ICD-10 criteria are more commonly used outside of North America.
A systematic review of the literature in 2007 found that the worldwide prevalence of ADHD was 5.29%, and that there were no significant differences in prevalence rates between North America and Europe. The review did find differences between prevalence rates in North America and those in Africa and the Middle East, but cautioned that this may be due to the small number of studies available from those regions.
Norwegian National Broadcasting (NRK) broadcast a short television series in early 2005 on the extreme increase in the use of Ritalin and Concerta for children. Sales were six times higher in 2004 than in 2002. The series included the announcement of a successful group therapy program for 127 unmedicated children aged four to eight, some with ADHD and some with oppositional defiant disorder.
Members of the anti-psychiatry movement such as Fred Baughman and Peter Breggin have extensively used the popular media to criticize ADHD and medications used for ADHD. Baughman has also published articles about ADHD in peer reviewed journals. They have testified at Congressional hearings on the use of Ritalin and supported legal challenges such as the Ritalin class action lawsuits. There is also a movement called critical psychiatry that often refers to their writings, but in contrast to Scientologists (see below), they are not "anti-psychiatry," but critics of some of its practices and offer alternative models and perspectives.
The Church of Scientology, which opposes all psychiatric treatment, has vocally criticized ADHD and its treatments and played a leading role in the anti-Ritalin campaign in the late 1980s. The church states that mental disorders are a fraud, "mental and behavioral problems are largely incorrect diagnoses that cover symptoms and don't handle the real problems, which may be physical or spiritual".
Some believe that many of the traits of those diagnosed with ADHD are personality traits and are not indicative of a disorder. These traits may be undesirable in modern society, leading to difficulty functioning in society, and thus have been labeled as a disorder. Some conservatives see ADHD as being an attack on masculine traits and the diagnosis and treatment of ADHD as an attack on traditional management of behavioral traits such as by discipline as well as intervention of the state into the sanctity of the family and the private citizen. Questions concerning the cause
The pathophysiology of ADHD is unclear and there are a number of competing theories.
ADHD as a biological illness
One of the most controversial issues regarding ADHD is whether it is wholly or even predominantly a biological illness leading to a chemical or structural defect in the brain. The current predominance of opinion in medicine is that ADHD is a mixture of genetics and the environment however the pathophysiology is unclear at this time. Frequently observed differences in the brain between ADHD and non-ADHD patients have been discovered, but it is uncertain if or how these differences give rise to the symptoms of ADHD. Xavier Castellanos, the former head of ADHD research at the National Institute of Mental Health (NIMH), is "firmly convinced that ADHD is a biological illness", but he also noted, regarding our understanding ADHD and the brain, "We don't yet know what's going on in ADHD."  Neuroimaging and genetic studies have revealed associations with ADHD, however according to NICE ADHD itself does not represent a neurological disease.
In "Rethinking ADHD: International Perspectives" an alternative paradigm for ADHD argues that, while biological factors may obviously play a large role in difficulties sitting still and/or concentrating on schoolwork in some children, the vast majority of children manifesting this behavior do not have a biological deficit. For a variety of reasons they have failed to integrate into their psychology the ability to work at chores that are expected of them. Their restlessness and daydreaming is similar to the behavior of other, normal children when they are not engaged, and are bored and trapped by circumstances. Very frequently, children with ADHD have no difficulty concentrating on activities that they find to be interesting. When they are taught by a charismatic entertaining teacher, they similarly can concentrate.
Although ADHD is said to be highly heritable and twin studies suggest genetics are a factor in about 75% of ADHD cases, some nevertheless question the genetic connection. Dr. Joseph Glenmullen states, "no claim of a gene for a psychiatric condition has stood the test of time, in spite of popular misinformation. Although many theories exist, there is no definitive biological, neurological, or genetic etiology for 'mental illness'." His critics argue that ADHD is a heterogeneous disorder caused by a complex interaction of genetic and environmental factors and thus cannot be modeled accurately using the single gene theory. Authors of a review of ADHD etiology have noted: "Although several genome-wide searches have identified chromosomal regions that are predicted to contain genes that contribute to ADHD susceptibility, to date no single gene with a major contribution to ADHD has been identified."
The Online Mendelian Inheritance in Man (OMIM) database has a listing for ADHD under autosomal dominant heritable conditions, noting that multiple genes contribute to the disorder. OMIM currently lists 8 genes with variants known to contribute to ADHD.
Neuroimaging and ADHD
See also: Attention-deficit hyperactivity disorder#Pathophysiology
Various types of neuroimaging suggest there are differences in the brain, such as thinner regions of the cortex, between individuals with and without ADHD. The methodology of some lobar volumetric studies used to evaluate cortex thinning in ADHD has been criticized as having "troubling reductionistic emphasis." Critics contend that in some studies, the controls for stimulant medication usage were inadequate which makes it impossible to determine whether ADHD itself or psychotropic medication used to treat ADHD is responsible for decreased thickness observed in certain brain regions. Jonathan Leo and David Cohen, who reject the characterization of ADHD as a disorder, believe many neuroimaging studies are oversimplified in both popular and scientific discourse and given undue weight despite deficiencies in experimental methodology.
 Hunter vs. farmer theory of ADHD
Main article: Hunter vs. farmer theory
The hunter vs. farmer theory is a hypothesis proposed by author Thom Hartmann about the origins of attention-deficit hyperactivity disorder (ADHD). He believes that these conditions may be a result of adaptive behavior of the species, his theory states that those with ADHD retain some of the older hunter characteristics.
Main article: Neurodiversity
Proponents of this theory assert that atypical (neurodivergent) neurological development is a normal human difference that is to be tolerated and respected as any other human difference. They usually support treatment or therapy, but may or may not agree with the use of medication. Social critics argue that while biological factors may obviously play a large role in difficulties sitting still and/or concentrating on schoolwork in some children, for a variety of reasons they have failed to integrate into the social expectations that others have of them.
 Social construct theory of ADHD
Main article: Social construct theory of ADHD
It has been argued that even if it is a social construct, this does not mean it is not a valid condition, for example obesity has different cultural constructs but yet has demonstratable adverse effects associated with it. A minority of these critics maintain that ADHD was "invented and not discovered". They believe that no disorder exists and that the behavior observed is not abnormal and can be better explained by environmental causes or just the personality of the "patient."
Concerns about medication
Main article: Attention-deficit hyperactivity disorder management
The National Institute of Mental Health recommends stimulants for the treatment of ADHD, and states that, "under medical supervision, stimulant medications are considered safe". A 2007 drug class review found no evidence of any differences in efficacy or side effects in the stimulants commonly prescribed. However, the use of stimulant medications for the treatment of ADHD has generated controversy because of undesirable side effects, uncertain long term effects, and social and ethical issues regarding their use and dispensation.
Frequency of stimulant use
In the 1990s the United States used 90% of the stimulants produced globally, in the 2000s this has decreased to 80% due to increased use in other areas of the world. The UK uses one tenth while France and Italy use one twentieth the methylphenidate per capita as the USA.
Concerns about side effects and long term effectiveness
Some parents and professionals have raised questions about the side effects of drugs and their long term use. A study by Dr. Peter Jensen, et. al, into long-term effects shows that medication does not have a significant advantage over behavioral management at three years, despite showing a benefit at 14 and 24 months. This has led to interest in non-drug treatments such as omega-3 oils which can help symptoms of ADHD. On February 9, 2006, the U.S. Food and Drug Administration voted to recommend a "black-box" warning describing the cardiovascular risks of stimulant drugs used to treat ADHD.
A 2008 review found that the use of stimulants improved teachers' and parents' ratings of behavior; however, it did not improve academic achievement. The same review also indicates growth retardation for children consistently medicated over three years, compared to unmedicated children in the study. Intensive treatment for 14 months has no effect on long term outcomes 8 years later. No significant differences between the various drugs in terms of efficacy or side effects have been found.
Animal research on the neurotoxicity of amphetamines has found contradictory results. For example in rats doses of amphetamines equivalent to those used therapeutically to treat ADHD were suggestive of benefits to the dopamine system. In primates therapeutic equivalent doses were found to cause reductions in striatal dopamine transporter density. Humans with ADHD were also found to have increased striatal dopamine transporter density that is reduced by ADHD medications. More research has been recommended into the long-term effects of amphetamines in the treatment of ADHD.
 Long term effects
Methylphenidate, an amphetamine derivative and potent central nervous system stimulant, can also lead to a psychosis from chronic use. Although the safety profile of short-term methylphenidate therapy in clinical trials has been well established, repeated use of psychostimulants such as methylphenidate is less clear. Long term effects of methylphenidate, such as drug addiction, withdrawal reactions and psychosis, have received very little research attention and thus are largely unknown. There is limited data regarding long term use of stimulants which suggests that there may be modest benefits in correctly diagnosed children with ADHD but there are also overall modest risks. The long term effects on the developing brain and on mental health disorders in later life of chronic use of methylphenidate is unknown. Despite this, between 0.51% to 1.23% of children between the ages of 2 and 6 years take stimulants in the USA. Stimulants drugs are not approved for this age group.
While ADHD is associated with an increased risk of substance abuse, stimulant medications have been shown to reduce the risk of subsequent development of substance abuse.
Concerns have been raised that long-term therapy might cause paranoia, schizophrenia and behavioral sensitization, similar to other stimulants. Psychotic symptoms from methylphenidate can include hearing voices, visual hallucinations, urges to harm oneself, severe anxiety, euphoria, grandiosity, paranoid delusions, confusion, increased aggression and irritability. It is unpredictable in whom methylphenidate psychosis will occur. Family history of mental illness does not predict the incidence of stimulant toxicosis in ADHD children. High rates of childhood stimulant use have been noted in patients with a diagnosis of schizophrenia and bipolar disorder independent of ADHD. Individuals with a diagnosis of bipolar or schizophrenia who were prescribed stimulants during childhood typically have a significantly earlier onset of the psychotic disorder and suffer a more severe clinical course of psychotic disorder in children who are vulnerable to psychotic disorders.
Young ADHD patients taking stimulant medication may have a reduced rate of height and weight gain during adolescence, but stimulant medication has little effect on the ultimate weight and height of the medicated patient. It is unclear whether the delay in growth is due to stimulant medication or ADHD itself; ethical problems in giving stimulant medication to children without ADHD as experimental controls makes such studies problematic. Some patients will take a period of time off of medication, called a "drug holiday," in hopes of allowing the normal rate of height and weight attainment to resume. Stimulant medication may also inhibit cartilage growth, liver development and central nervous system growth factors. Periodic CBC, differential, and platelet counts are recommended during prolonged use of methylphenidate.
It is often not a child's decision to take medication, especially those under the age of six, a group that is seeing a dramatic increase in the prescription of psychiatric medications. Some schools have attempted to require treatment with medications before allowing a child to attend school. The United States has passed a bill against this practice. Thus ethical concerns regarding forced treatment or coercion of minors arise. Some suspect that children are using stimulants as a cognitive enhancer at the request of their achievement-oriented parents.
 Non specific nature
Stimulants are often seen as cognitive enhancers or smart drugs. Their effects are non-specific with similar results seen in children and adults with and without ADHD. One finds improved concentration and behavior in all. Due to their non-specific activity, stimulants have been used by writers to increase productivity, as well as by the United States Air Force to improve concentration in combat. A small number of scientists recommend widespread use by the population to increase brain power.
Stimulants are controlled psychotropic substances. They are classified as Schedule II substances (Schedule II: Potential for abuse; potential for psychological or physical addiction; currently accepted medical use).
Controversy has surrounded whether methylphenidate is as commonly abused as other stimulants with many[who?] proposing that its rate of abuse is much lower than other stimulants. However, the majority of studies assessing its abuse potential scores have determined that it has an abuse potential similar to that of cocaine and d-amphetamine.
Both children with and without ADHD abuse stimulants, with ADHD individuals being at the highest risk of abusing or diverting their stimulant prescriptions. Between 16 and 29 percent of students who are prescribed stimulants report diverting their prescriptions. Between 5 and 9 percent of grade/primary and high school children and between 5 and 35 percent of college students have used nonprescribed stimulants. Most often their motivation is to concentrate, improve alertness, "get high," or to experiment.
Stimulant medications may be resold by patients as recreational drugs, and methylphenidate (Ritalin) is used as a study aid by some students without ADHD.
Non-medical prescription stimulant use is high. A 2003 study found that non prescription use within the last year by college students in the US was 4.1%. A 2008 meta analysis found even higher rates of non prescribed stimulant use. It found 5% to 9% of grade school and high school children and 5% to 35% of college students used a nonprescribed stimulant in the last year.
Substance use disorders
There has been controversy surrounding whether ADHD is associated with increased rates of problematic substance misuse. In 2001 the evidence suggested that there was no increased risk of substance use disorders in ADHD children unless there is a co-existing conduct disorder. Studies investigating whether stimulant medication can lead to drug abuse later in life found that despite the higher rate of substance abuse among ADHD patients as a whole, stimulant medication use in childhood did not affect or lowered, the risk for substance of abuse in adulthood compared to unmedicated individuals with ADHD.
A 2009 review, and a 2006 study, found that those who had received stimulants during childhood showed the highest number of cocaine abusers in adulthood, twice that of the other groups thus suggesting that stimulant use during childhood was associated with sensitising or predisposing children to cocaine abuse later in life. Smoking tobacco also appeared to increase the risk of cocaine abuse in this population but even after controlling for tobacco exposure cocaine abuse was still significantly higher in adults who had been medicated with stimulants as children. This risk was still present 15 years after stimulant medication exposure.
In 2008 five pharmaceutical companies received warning from the FDA regarding false advertising and inappropriate professional slide decks related to ADHD medication. In September 2008 the FDA sent notices to Novartis Pharmaceuticals and Johnson & Johnson regarding advertisings of Focalin XR and Concerta in which they overstated products' efficacies. A similar warning was sent to Shire plc with respect to Adderall XR.
Financial conflicts of interest
Russell Barkley, a well known ADHD researcher, admits to taking money from drug companies for speaking and consultancy fees. There are concerns that this may bias his publications.
In 2008, it was revealed that Joseph Biederman of Harvard, a frequently cited ADHD expert, failed to report to Harvard that he had received $1.6 million from drug companies between 2000 and 2007. E. Fuller Torrey, executive director of the Stanley Medical Research Institute which finances psychiatric studies, said "In the area of child psychiatry in particular, we know much less than we should, and we desperately need research that is not influenced by industry money."
Children and Adults with Attention-Deficit/Hyperactivity Disorder, CHADD, an ADHD advocacy group based in Landover, MD received a total of $1,169,000 in 2007 from pharmaceutical companies. These donations made up 26 percent of their budget. This has been viewed by some as a major conflict of interest.